MENTAL HEALTH MOMENT
MENTAL HEALTH MOMENT
October 27, 2000
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"A room without books is like a body without a soul."
- Cicero
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China Cultural Tour
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DISASTER RECOVERY COUNSELING
The model discussed below is based on crisis counseling
programs used in disasters over several decades (Lebedun
and Wilson, 1989; Myers, 1994). This model assumes two
major dimensions for each target population of survivors:
* the psychological stage of disaster, and
* the intrusiveness of programs provided.
The Psychological Stages of Disaster include:
1. The Pre-disaster Stage - innoculation
which usually includes prevention and educational
programs which supply skills for preparing key
community resources (i.e. police, teachers, etc.)
for disasters.
2. The Heroic Stage is where crisis
intervention programming is delivered to survivors
together with emergency management efforts.
3. The Honeymoon Stage - crisis
intervention services are usually aimed at survivors
who are recovering from the initial impact of the
disaster. Services are generally delivered in
shelters, service centers, disaster assistance
centers and feeding sites.
4. The Disillusionment and Reconstruction Stages
- survivors begin working on recovery issues to
help put their lives back together. Programs in
these stages focus on providing disaster recovery
counseling, casework approaches, consultation
with gatekeepers, partnerships with other disaster
and community resources, networking groups, and
community organizations.
The intrusiveness dimension of programs suggests that
effective programs are ones closest to survivors
spatially, temporally, and psycho-socially with no
restrictions on funding. These characteristics also
suggest how programs should be delivered, depending
on the disaster phase. A menu of services used might
include: recovery/information, skill-building,
mobilization of community resources, natural group
crisis counseling, individual and family outreach
crisis counseling, recovery counseling, and community organization.
Below is a list of disaster intervention programs
with cost/person from low to high cost:
Low Cost Recovery Education and Counseling
Mobilizing Community Resources
Community Organization
Training and Consultation
Skillbuilding Gatekeepers
Natural Group Counseling
High Cost Recovery Counseling
Disaster Intervention Program Strategies
The most pressing needs of survivors must be dealt
with first. Maslow's (1943) Heirarchy of Needs is
the best approach in analyzing how to address this
area. Below are listed, in increasing order, Maslow's
Heirarchy of Needs:
1. Basic Psychological Needs
2. Safety and Security
3. Affection and Social Activity
4. Esteem, status
5. Self-realization
Most basic are survival and security needs. These are
paramount in the early phases of a disaster. When
these needs are addressed, the survivor can move from
immediate needs to longer term recovery and higher
order needs.
As a result, the model we are discussing is designed
to be flexible yet comprehensive. Not every individual,
or target group, is going to need every service at
each phase. Survivors' needs must continually be
assessed in order to modify approaches and use the tools
which are most salient at each phase of the recovery
process. It is also very important to anticipate the
next level of needs for the target individual, family
or population so that timely changes can be made in
program strategies.
For example, a target population might be farmers. There
is sparse literature describing the needs of farmers
following disasters. Mermelstein and Sundet (1986)
described a survey of mental health centers concerning
the need for mental health services among farmers as a
result of the Midwest farm crisis. The results showed
that 64% of survey respondents indicated a "precipitous"
increase in caseloads attributable to the crisis. The
four most prevalent conditions were depression,
withdrawal-denial, crisis behaviors, and alcohol and
other drug abuse. Heffernan and Heffernan (1986) carried
out a landmark study of stress following the farm crisis.
This study demonstrated that "about one fourth of the
men and women indicated they had increased smoking.
Eighteen percent of the men and twelve percent of the
women said they experienced an increase in their
drinking." Anecdotal information collected by the
National Association of Mental Health (1987) during
the farm crisis suggests that increased substance abuse
was a result of the crisis. While not directly related
to disasters, these studies are informative about how
farmers react to stressors.
For a comprehensive disaster outreach model to be
applicable from disaster to disaster, regardless of the
type or even severity of the disaster, several key
threads must be woven throughout the stages and addressed
appropriately. These include the heirarchy of needs that
require resolution. Using Maslow's model, needs range
from basic food, water, shelter, and safety to recognition
and self actualization. This holds true whether the
population is farmers, school age children, elderly
citizens, etc.
Model For Disaster Recovery
There are 5 basic principles for developing a successful
disaster recovery program:
1. The program must be woven into the surviving
infrastructure of the community. It must optimally
use the strengths that are already present, including
family ties, neighborhood networks, schools, church
affiliation, etc. It must also minimally disrupt the
surviving infrastructure.
2. The program must be close to the survivors, in
distance, in time, and in culture (and have no
economic barrier). The program must minimize
distance. The best way to do this is for the survivors
to achieve ownership of the program.
3. The program must match the phase of recovery of the
survivors. Programs geared to the "Honeymoon"
phase will be minimally effective in the "Disillusionment"
phase. The successful disaster recovery program is
constantly being reinvented.
4. The program must use a range of tools to reach
survivors on many levels simultaneously
5. The program must be tailored to the needs of
individual survivors and target groups. What
works in the city may be useless with rural families,
and vice versa. Even more than special efforts,
tailored strategies must be designed to address the
needs of specific age groups - older adults, preschoolers,
adolescents, etc.
Designing A Disaster Recovery Counseling Program
1. Building on the Surviving Infrastructure
The primary rule of any intervention is "first, do no
harm". For example, a number of years ago following a
widespread flood in the Northeast, the Federal government
devised a program to address the temporary housing needs
of survivors by arranging mobile homes for them. The
government was criticized, however, when decisions on
who received the next trailer seemed to be based on local
political connections rather than greatest need. Therefore,
the program was removed from local influence. However,
the end result was the breaking up of local neighborhoods
when trailer assignments were made.
Each family registered with the Federal government and
an extensive review of their current circumstances and
needs was conducted. Then they waited, not receiving any
feedback on the status of their applications. At some
point, the family would be advised that they were next
in line and be told that they would be assigned the next
available trailer. However, the next available trailer
might be ten miles up river on the opposite bank in a
culturally different community. People were not given
a choice as to where they could live, or if they could
relocate close to others with whom they had established
relationships. Neighbors were often assigned to the other
side of the river many miles downstream. Children then
went to different schools, where none or few of their
friends attended.
An unintended side-effect of this program which addressed
one need, temporary housing, was to sacrifice many of the
strengths that individuals, families and communities had
which could have added to and hastened their recovery.
Instead, survivors reported additional secondary problems:
school maladjustment and decreased performance; increased
incidents of family violence, including child abuse;
increased use and abuse of alcohol and other drugs. Of
course, to meet the temporary housing needs of survivors,
a primary need, some disruption was inevitable. The question
should be asked: "Could disruption have been minimized
if survivors were given more choice in where they lived
in order to preserve their previous neighborhood networks,
or to choose locations and neighborhoods with the least
cultural distance."
The Federal government revised many of its policies in
regard to housing since the above example occurred
over 25 years ago. However, one of the major difficulties
survivors still report is in dealing with the consequences
of temporary housing. Our role, then, when dealing with
basic survivor needs - in this case temporary housing -
is to preserve as much of the social infrastructure as
possible. We need to help people develop good alternatives
when the fabric of their community is torn.
But what is our role when no infrastructure exists?
For instance, in third world nations? When a hurricane
hit a Carribean island, disaster relief personnel were
dispersed to the hills where a mud slide was said to have
devastated a conclave of several thousand people. When
they arrived, the "town" was composed of more than ten
times as many people as anticipated. These disenfranchised
people were officially non-existent. No official map
marked the streets, potable water was unavailable, and
people were drinking water from ditches. Food had not
been distributed in days. A needs assessment that
should have taken days took weeks to complete. It was
impossible to tell who owned pieces of boards or corrugated
tin roofs which had blown away. So there were many disputes
over ownership. Obviously, the needs of these survivors
were more basic than in most disasters in the continental
United States. And yet, there were still informal
community leaders who could be identified and some
community assets, no matter how meager, to form the basis
of recovery.
2. Getting Close To The Survivors
An axiom of psychological intervention is that as distance
increases, the effectiveness of the intervention decreases
Distance is not just spatial, it can also be measured in
time, economic barriers, and cultural or psycho-social
distance. Disaster recovery is most effective when distance
is minimized by working closely with survivors in terms
of time, economics, cultural, spatial, and psycho-social
distance. In other words, there is an optimal place, time
and approach to survivors in order to maximize their
receptivity to intervention.
For example, in the early days of the development of
disaster counseling programs, an effort was made by a
community mental health center to respond to a commuter
train wreck with a large number of fatalities. Few solid
models of disaster counseling programs were available, so
the community mental health center did what it could. It
obtained a list of the families of victims and of
survivors of the crash and sent them letters making
available counseling groups. When few people responded,
staff concluded, probably erroneously, that survivors
of disasters and families of victims do not need special
interventions.
In the two-plus decades since that incident, there have
been many disasters and many fine examples of disaster
recovery programs which have had a much more positive
result than that pioneer community mental health center.
With the train wreck, initially the mental health center
created great distance from the survivors in a number of
ways:
1. Spatially - the intervention was placed at the
mental health center, which was near the site of the
wreck, but it meant that survivors, who largely lived
in remote suburbs, had to again travel by train to access
the center for an intervention.
2. Temporally - the mental health center did not
survey survivors to pick optimal times for interventions
which would fit into the survivors' lives. The mental
health center did not respond immediately to the disaster,
although they could still have an impact in later phases
of disaster (this would make it more difficult to gain
credibility).
3. Psycho-socially/culturally - the mental health
center was providing a clearly labeled mental health
response to a man-made disaster. Most people in disaster
situations do not see themselves as having a mental health
problem. They feel they just need help to sort things out.
If the mental health center had intervened at a more neutral
site, and in conjunction with a "gatekeeper" or "partner"
who was closer socially and psychologically to the
survivors, there was a better chance that it would have
been effective. Such a gatekeeper or partner could have
been a neighborhood school (i.e. from the survivors'
neighborhoods) or church. The mental health center did
not have much economic distance as they were not charging
for services. However, people would have had to pay train
fare to gain access to the mental health center for services.
Another way of conceptualizing distance is as an "onion
skin" with the survivor at the center. In concentric layers
moving out from the middle are family, neighbors, friends,
coworkers, and extended family, familiar gatekeepers
(i.e. clergy, teachers, employers, etc.), local agencies
which might have low stigma or a mandate to serve in this
situation (the Red Cross, Salvation Army, law enforcement,
hospitals, emergency management), and, finally, higher
distance or stigmatized organizations, like mental health
centers.
The above examples may not be at the same distances for
everyone. The "onion" model is idiosyncratic, individualized
from survivor to survivor. The best method is to form
partnerships with gatekeepers close to survivors. For
example, providing programs through the Red Cross or
Salvation Army or similar groups in early stages of the
disaster and transitioning to programs in partnership
with the schools (for children), county extension services
(for rural families), or Meals on Wheels program (for older
adults), reduce distance.
3. Matching The Phase Of Recovery
It is hard to conceive of a more demanding endeavor than
providing disaster recovery services. Ordinarily for a
community, unmet needs are assessed which may trend up
or down, but which are relatively stable over time.
Programs are then designed and adjusted over time, based
on outcome results.
Disaster recovery presents us with a moving target.
Survivors' needs change dramatically from Impact (the
Heroic Phase) to Recovery. Programs must anticipate
changes in needs and adjust accordingly. Some of these
adjustments can mean changes in partnerships and even
changes in the mix of personnel at each phase. A program
may be on target and effective one month and fading and
seemingly irrelevant the next. One can misinterpret
that the survivors' needs have diminished. Slackening
of a need for that program can be confused with a
decline in overall needs of the survivor. More likely,
the need hasn't diminished. It has changed, and we need
different tools or an adjustment in current tools to
remain effective.
4. Providing A Range Of Strategies
Disaster recovery programs can be as diverse as the
community of survivors needing to be served. When disaster
recovery programs were first developed, over two-plus
decades ago, the "best fit" model was crisis intervention,
which evolved from the suicide and crisis intervention
hotline movement (McGee, 1974). The crisis intervention
model offered an alternative to individual or group
therapy. If you will recall, an earlier example was given
of an unsuccessful attempt by a community mental health
center to help the survivors of a train wreck using
office-based group therapy.
Crisis intervention is still a useful tool. It is most
useful in the Heroic and Honeymoon stages. However, most
disaster program efforts will go into the much longer
Disillusionment Phase, where crisis intervention is
more limited as a tool.
In the last two-plus decades, a number of useful,
effective tools have been developed. They can be
classified along a continuum, based on how "intrusive"
the strategy is to the survivor. The least intrusive
strategies are those which use existing channels of
communication to give information to the general public
or a target group. The former might be a newspaper
article on the reaction of young children to disasters.
The latter might be a version which can be given to day
care centers, schools or churches to send out in their
newsletters.
Next along the intrusiveness dimension would be strategies
which build skills in target populations using natural
groups. With school-age children, for example, this can
be done indirectly by training teachers on the reactions
of children to disaster and providing teachers with
useful curricula. Or, it can be done directly, by taking
the program directions to the formed groups in their
natural settings such as going into the classroom itself.
Next along the continuum are community organization
strategies. The goal of these strategies is to "jump start"
or empower the community towards its own recovery. This
can involve working with community leaders to develop a
locator or voluntary register service so survivors in
temporary housing can be contacted by and themselves contact
former neighbors and friends. It can involve helping to
put together a disaster anniversary party to bring
people together. Or, it might involve organizing a
baby-sitting co-op in a motel where a number of young
families are temporarily housed. The continuum of
strategies progresses through group and individual
counseling and case management services.
5. Tailoring Programs To Target Groups
An easily made mistake is to believe a full range or
continuum of services exists only to find that the
continuum is only complete when target groups overlap.
When these target groups are looked at separately, large
holes may be evident. For example, a variety of community
education and skill building may be available, but only
for children. Variations on these strategies could be
developed for older adults as well. Or, a large number
of people may be reached, but one or more socioeconomic
groups remain under-represented.
If we put all the pieces together, the model has three
dimensions. On one dimension are the Phases of Disaster.
On another is the Range of Strategies of interventions.
On the third dimension are the Special Groups Targeted.
The comprehensiveness of programs can be evaluated if with
each group and, at each phase, we have a full continuum
of strategies.
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go to the url below and begin by trying the following
descriptors in the search engine: Disaster recovery, stages
of disaster, crisis intervention and disasters, survivors
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https://www.angelfire.com/biz/odochartaigh/searchbooks.html
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Contact your local Mental Health Center or
check the yellow pages for counselors, psychologists,
therapists, and other Mental health Professionals in
your area for further information.
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